Recent meta-analysis that suggests aspirin might be as effective as some commonly used anticoagulants in preventing VTE following hip and knee replacement surgeries makes a case for further study, says a veteran hospitalist.
"Whereas we currently have a number of alternatives [at variable cost and efficacy] for preoperative prophylaxis against DVT and ensuing complications, we may be able to ultimately standardize a prophylactic regimen," Jairy C. Hunter, MD, MBA, SFHM, associate executive medical director for case management and care transitions at the Medical University of South Carolina in Charleston told The Hospitalist in an email. "If aspirin is found to be effective and safe as part of that regimen, then we can improve outcomes, as well as cost, while reducing the risk of complications from the prophylactic regimen itself."
Recently published in the Journal of Hospital Medicine, the paper reviewed eight randomized clinical trials comparing aspirin to anticoagulants for prevention of VTE following major lower extremity surgery (hip or knee replacement). Researchers' analysis included 1,408 participants and compared data on VTE, bleeding, and mortality risk with the type of medication involved.
The authors found aspirin to be as effective as anticoagulants for preventing VTE after lower extremity arthroplasty and linked it with lower bleeding risk after these surgeries. Aspirin also carried a lower risk of bleeding in patients following hip fracture repair, but researchers noted it might be linked with a higher risk of DVT in these patients, making anticoagulants a better choice for VTE prophylaxis post-hip fracture repair.
Frank Drescher, MD, assistant professor of medicine at the Geisel School of Medicine at Dartmouth in Hanover, N.H., and lead author of the research, says he was surprised to see anticoagulants—often considered the stronger medication—made no difference compared with aspirin in lowering DVT risk with hip and knee replacement surgeries. He contends that patients' behavior post-surgery may make a difference.
"Early mobilization and pneumatic compression devices can help to prevent [VTE]," Dr. Dresher told The Hospitalist in an email. "It's possible that increasing use of non-pharmacological measures helps to mitigate differences between different pharmacological agents."
Hospitalists routinely see hip fracture repair patients and become involved in the orthopedic management of DVT prophylaxis, according to Anand Kartha, MD, MS, an academic hospitalist in the Veterans Affairs Boston Healthcare System and a member of Team Hospitalist. He says the research strengthens the idea "that physicians should not use aspirin on hip fracture patients for DVT prophylaxis or prevention" after surgery.
Dr. Drescher acknowledges some limitations of his meta-analysis, including the fact that researchers found few randomized trials with direct comparisons between aspirin and anticoagulants, and some trials were more than 10 years old. In the future, Dr. Drescher says he hopes to see more research on this topic.
Dr. Kartha agrees but says the first step is ensuring consistent use of the existing research. "Rather than debating the validity of one therapy versus the other…what is needed is consistent application of what is already known," he explains. "That is, there needs to be a standardized, institutional approach to this issue."TH